Abstract

BackgroundScreening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality.MethodsThe fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome.ResultsWe found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress.ConclusionThere are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.

Highlights

  • Most pregnancies progress normally, some are more complex because of antenatal or intrapartum conditions that place the mother, the developing fetus, or both at a higher risk for complications than pregnancies without these conditions

  • This lack of impact may be complex: Doppler ultrasound may not identify a sufficient proportion of flow abnormalities to measurably impact stillbirth incidence; Doppler-detected abnormalities may not be subsequently monitored appropriately with other tests of fetal well-being and serial Doppler testing; intervention based on abnormal Doppler may not work; or high rates of false-positives may unnecessarily expose the fetus to the risk of preterm birth, if gestational age dating is inaccurate

  • Retrospective studies reveal declines in the incidence of stillbirth among diabetic women in low-prevalence populations where diabetes care is available [86], few prospective trials have been able to show any impact on stillbirths or perinatal mortality, largely owing to the high sample sizes required for such studies [63]

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Summary

Introduction

Most pregnancies progress normally, some are more complex because of antenatal or intrapartum conditions that place the mother, the developing fetus, or both at a higher risk for complications than pregnancies without these conditions. Non-invasive techniques exist to screen for a number of these conditions during the antenatal and intrapartum periods. These screening tools can be used to monitor fetal well-being via assessment of fetal movement, heart rate, and/or growth; and feto-placental and/or uteroplacental circulatory dynamics, whether routinely at antenatal care (ANC) visits or via more complex screening tests in high-risk and post-term pregnancies [3]. On the other hand, screening and monitoring techniques during pregnancy and the intrapartum period could inadvertently result in avoidable perinatal deaths, either because the technique itself is harmful or because it increases the risk of inappropriate or unnecessary use of drugs, induction of labour, early delivery, or Caesarean section. Appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality

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